MEDICARE & HEALTH INSURANCE DETAILS:

Medicare Details:

Private Health Insurance:

Fund Name:
Member No:
Dental Extras Fund:NoYes
Hospital Cover:NoYes

Veteran Affairs:

Card No:
Expiry Date:

TAC/Workcover

Insurer:
Claim No:
Claims Contact:

MEDICAL SUMMARY

HAVE YOU HAD OR CURRENTLY HAVE:Rheumatic feverNoYesDiabetesNoYesHeart problemsNoYesHeart murmurNoYesEpilepsyNoYesKidney diseaseNoYesHepatitisNoYesAsthmaNoYesHigh blood pressureNoYesOsteoporosisNoYesStomach reflux/ulcerNoYesExcessive bleedingNoYes

DO YOU HAVE ANY ALLERGIES TO:PenicillinNoYesAspirinNoYesLatexNoYesElastoplast or tapesNoYes

Any other medication allergies?: NoYes If yes, please provide details in box below (180 or less characters):
Any food allergies?: NoYes
Any other allergies?: NoYes If yes, please provide details in box below (180 or less characters):
Have you smoked cigarettes/cigars within the last 4 weeks?: NoYes
Are there any other "risk factors" you need to discuss in your consultation? (180 or less characters):
Have you EVER taken any medications for osteoporosis or bone conditions/lesions? (eg. Fosamax, Actonel, Zometa, Pamisol, Didronel, Didrocal, or Aredia): NoYes
Please list ALL medications you are currently taking (including vitamin supplements and inhalers) (180 or less characters):
Please list ALL previous operations (180 or less characters):
Describe any serious illness you have previously suffered (180 or less characters):

General Anaesthetics

Have you had problems with general anaesthetics or a family history of malignant hyperthermia? (180 or less characters):

Females

Are you pregnant?: NoYes
Are you taking the oral contraceptive pill?: NoYes

PRIVACY STATEMENT

Our practice respects your right to privacy and complies with the legislation relating to the collection, storage, use and disclosure of health information. For more information please ask for the Privacy Statement handout.

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